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VA woes across the country led NH to reforms

By TIM BUCKLANDNew Hampshire Union Leader

6/28/2014 Korean War Veterans from NH gathered Saturday afternoon at the NH Army National Guard Aviation Support Facility in Concord at a ceremony co-hosted by the Korean American Society of New Hampshire and the State of NH to recognize and pay tribute to the vets. The event is held annually. Earl Kimball, of Allenstown, and Bud Durling, of Pembroke, pose with Senator Kelly Ayotte after the ceremonies. Kimball served in Korea in the Marines from 1951-1953 while Durling served in the Navy Seabees from 1952-1960. Bruce Taylor/Union Leader

MANCHESTER - A little over two years ago, a former Veterans Affairs administrator from Manchester gave a Senate committee warnings about Department of Veterans Affairs issues that in the last two months have become a national scandal.

Nick Tolentino, who resigned as a mental health administrative officer at the Manchester VA Medical Center in December 2011, told the Senate Veterans Affairs Committee in April 2012 that the emphasis on meeting performance measures outweighed the needs of veterans."Performance measures are well-intentioned," Tolentino, who could not be reached for this story, told senators at the time. "But they are linked to executive pay and bonuses and, as a result, create incentives to find loopholes that allow the facility to meet its numbers without actually providing the services."

His testimony was reported in several media outlets, including the New Hampshire Union Leader, but it wasn't until CNN reported in April that the Phoenix VA manipulated waiting lists to secure employee bonuses, allegedly resulting in as many as 40 veterans dying while waiting to be seen by doctors, that Congress sprang into action with new legislation and calls for the resignation of VA Secretary Eric Shinseki, who stepped down May 30.

But Tolentino's testimony wasn't limited to performance measures and bonuses, as he also reported that the Manchester facility was, among other things, woefully understaffed and that a clinician was drunk on the job, with no moves made to fire the clinician.

Issues addressed

New Hampshire Sens. Jeanne Shaheen, a Democrat, and Kelly Ayotte, a Republican, have this year authored or co-sponsored legislation, often co-authoring bills together, to address the VA waitlist crisis.

Those have included measures that would allow veterans who live far from a VA facility to access care at private hospitals and would force employees who manipulated wait-time data to give back any bonuses.

While both senators met with Tolentino two years ago and have worked on veterans issues in the last two years, their offices said the waitlist issue didn't come to the forefront in 2012, given Tolentino's report on the other problems specific to the Manchester VA.

"Based on her meeting with Nick Tolentino, Sen. Ayotte's focus was on making sure the problems identified at the Manchester VA were being quickly and fully addressed, and her office followed up immediately with VA officials in Manchester," said Liz Johnson, Ayotte's press secretary. "She has long pushed the VA to improve access to care for New Hampshire veterans, who too often have to wait in line or travel hours to receive health services out of state."

"In response to the inspector general's report and her meeting with Mr. Tolentino, Sen. Shaheen worked to make sure the VA in Manchester had resources to expand their capacity for care," said Elizabeth Kenigsberg, Shaheen's press secretary. "She also supported efforts to expand mental health care treatment and voted for the hiring of additional mental health professionals to make sure the VA could appropriately serve our veterans."

Updates sought

Johnson and Kenigsberg said Ayotte and Shaheen met with Manchester VA officials to get updates on what the facility was doing to address Tolentino's complaint.

The senators' other work in the last two years included efforts aimed at providing more access to VA facilities for veterans living in New Hampshire's North Country, which resulted in new facilities opening in Colebrook and Berlin, and calls on the VA to do something about the backlog of veterans disability claims, which was the issue dominating the news about the VA at the time.

"I've been working to address the ongoing claims backlog at the VA for years now, and in light of the recent mismanagement scandal, it's obvious that sweeping reforms are necessary," Shaheen said. "At the same time, New Hampshire veterans have faced serious hardships within the VA system, such as enduring long drives to neighboring states for care, and I have also been working to help them access care closer to home."

"Most recently, Sen. Ayotte worked with Sen. Shaheen to include in the VA reform bill that recently passed the Senate a provision that will give veterans the option of seeking care from a private provider if they reside in a state without a full-service VA medical facility - such as New Hampshire - and live more than 20 miles from the nearest full-service VA hospital," Johnson said.

Changes at Manchester VA

Tammy Krueger, director of the Manchester VA, said the facility made changes in its mental health services beginning in 2012 and continuing this year, primarily because of Tolentino's complaints to VA executives and his subsequent testimony in front of the Senate.

"We took it very seriously," she said. "We took it seriously from the moment he raised the issues."

She said the changes include a near-doubling of mental health staff and an overhaul of performance measures. A report conducted by the VA inspector general showed that Manchester's actual wait time for a new patient to be seen by a doctor was seven days. The standard is 14 days.

The VA's mental health staff has increased from about 40 at the time of Tolentino's departure to 67 today, Krueger said. Of those 67, nearly 90 percent are clinicians, according to information provided by the VA.

"We knew we had a shortage in staff in mental health," Krueger said. "We have had significant increases in resources in supporting staff and in caring for veterans."

She said the Manchester VA also changed how it measures performance. During Tolentino's time at the facility, she said, staff was asked about their performance daily. Now, the discussions happen monthly to relieve employees of that daily pressure, she said.

"I think there was certainly more emphasis on performance measures than there should have been," Krueger said. "We said two years ago that the performance measures should not be a daily focus or a specific conversation on a daily basis."

No false data

While the inspector general found evidence that employees at some facilities had deliberately altered wait time data to ensure bonuses, Krueger said no such evidence was found at the Manchester facility.

"But I think there was undue pressure in the conversations about performance measures. That may have provided extra stress," she said. "We made the changes to get us to a more positive place."

She said the facility has also enhanced its peer support network, a justice outreach program for veterans accused of crimes and its family counseling services.

In a service that she said is unique to Manchester, a program was created so that veterans' mental health needs are now tracked by a team of three clinicians, rather than one. The program has meant that if veterans need to talk to someone or need to be seen, they won't have to wait for their primary care provider to return from a vacation or a day off. This has resulted in more timely care, she said.

"They all know you in a unique way," she said. If one of the three isn't available, "one of the other people on your team would be able to help you right then."